AB0749 FAST TRACK GIANT CELL ARTERITIS SERVICE IN A DISTRICT GENERAL HOSPITAL USING ULTRASOUND DOPPLER IMAGING
Authors: P. Kamperidis, A. Hall, R. Wickramarachchi, H. Perera, S. Panthakalam
Journal: Annals of the Rheumatic Diseases (2023)

<h3>Background</h3> Giant Cell Arteritis (GCA) is the commonest large and medium artery vasculitis affecting patients aged 50 or above. It is a multisystem, inflammatory condition that can result in significant comorbidity, even mortality. Corticosteroids form the mainstay in remission induction and play a vital role in maintenance therapy. Complications can arise either due to delayed treatment, or unnecessary treatment of GCA mimics due to steroid side effects. This renders quick diagnosis a pivotal first step in its management. Temporal Artery Biopsy (TAB) has traditionally been the golden standard diagnostic modality, but it requires a surgical setting, resulting in delays. On the other hand, temporal artery Ultrasound Doppler Scan (USS) under an expert clinician has been incorporated by both BSR and EULAR in their recommendations. This offers a diagnostic tool with high specificity and sensitivity. <h3>Objectives:</h3> 1.To set up a Fast Track GCA clinic and a referral pathway to allow timely diagnosis in an one-stop-shop outpatient (OPD) clinical setting with inhouse USS 2.To limit dependence of GCA diagnosis on TAB <h3>Methods</h3> We set up a weekly dedicated GCA OPD clinic at Eastbourne District General Hospital (EDGH) aiming to see patients within five days of referral. Upon review, patients were categorised to low, moderate or high GCA risk via a pretest probability score. Patients scoring high, moderate, or low but with diagnostic uncertainty, had temporal artery USS by an expert Rheumatologist on the day. We collected data on number of USS performed, scan outcomes, and TAB requests over a six-month period between May and December 2022. <h3>Results</h3> Total number of referred patients with suspected GCA was 50, 18 male and 32 female. Referral source was mainly via General Practice (GP) and Ophthalmology. Out of the 50 total, 49 had already been commenced on corticosteroids. All patients (100%) were seen within five days of the referral and had their pretest probability scores worked out in the clinic. Overall, 42 patients (84%) had USS and 6 (12%) were scanned within 72 hours of steroid commencement by the referrer. Eight patients (16%) were not scanned: six of them had very low probability score and were given alternative diagnoses without a diagnostic test; one was out of the window for diagnostics due to the timing of steroid commencement; one could not be scanned due to technical reasons, so a TAB was requested. Crucially, this was the only TAB requested during this period. GCA diagnosis was comfortably made for 21 out of the 42 patients scanned (50%). We ruled out GCA in the rest of the scanned patients (50%). <h3>Conclusion</h3> A pilot Fast Track clinic at EDGH facilitated prompt diagnosis of GCA with the use of USS. In a period of six months, we were able to confidently diagnose or rule out GCA in 100% of our scanned patients, without the need for a TAB. Such a set up enables prompt diagnosis of GCA and timely commencement of the appropriate steroid-weaning regimen, thus avoiding any future complications. Crucially, it allows the timely discontinuation of GP-commenced steroid therapy in patients with excluded GCA, thus minimising side effects of an unnecessary treatment. Typically, it takes more than three weeks to arrange a TAB. USS use also avoids an invasive procedure with potential for surgical complications. Additionally, from a Healthcare System point of view, there are certain cost-saving implications in using USS for GCA diagnosis. These range from reduced OPD clinic time and diminished demand for theatre slots and staff, to minimisation of future complications from timely commencement or discontinuation of steroid management. We also observed improved patient experience. This study confirms the integral role of USS in a Fast Track GCA Service. <h3>References</h3> [1]Sebastian A, et al. Probability-based algorithm using ultrasound and additional tests for suspected GCA in a fast-track clinic. RMD Open. 2020 Sep;6(3):e001297 [2]Dejaco C, et al. EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice. Ann Rheum Dis 2018;77:636–643 <h3>Acknowledgements</h3> I have no acknowledgements to declare. <h3>Disclosure of Interests</h3> None Declared.